Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Prehospital Intubations and Mortality – comment from 30 ff/pm

Also posted over at Paramedicine 101. Go check out the rest of what is there.

In the comments to Prehospital Intubations and Mortality: A Level 1 Trauma Center Perspective I, 30 ff/pm wrote:

Like most studies done by someone who wants their name in a publication, this one is throws out some numbers as if they mean something.

To compare 4 diff. types of airway management and give the impression that there is a “relation with mortality” without giving at least a head nod to the INJURY is asinine.

I do not know what the motivations of the researchers[1] was, but it is good that they are publishing the results of their study, even though it makes them look really bad.

I would rather have them publicly face their problem, than cover it up and ignore it.

The type of injury should not matter. With a large enough sample size, there should be a wide enough variation in injuries, that the result falls into the category of normal distribution. A few really tough tubes should not make a big difference in this sample size.

The question is, Do they recognize what the problem is?

Sadly, I think we agree that the medical directors probably do not recognize that this is a problem of oversight, not so much a problem of bad medics. The medics were probably just doing what they were trained to do.

If they did 2 successful crics, what did they use for a tube? A Bic pen? If they used an ETT that pt IS TUBED, just not orally. That is NOT a failed intubation.

I will agree that this is successful airway management, if the crichothyrotomy truly was necessary. 1% is on the high side for crichothyrotomy rate, but this is such a small sample size that the numbers are well within the expected normal distribution of crichothyrotomies.

The term should be not a successful orotracheal intubation. You are correct, but it is not an important problem in my opinion. Their lack of understanding of airway management is a much greater problem.

Where we part ways in thought is your hairspltting “control” issues.

We never have control of the airway. Even a properly placed endotracheal tube does not mean control. Control suggests that something does what you want it to do.

We manage airways, i.e., we control them.

The airway may not do exactly what I want it to do – that’s why I have a laryngoscope in my hand in the 1st place – but with a tube in place it sure as hell is easier to manage than without it and that is control as far as airways go.

with a tube in place it sure as hell is easier to manage than without it and that is control as far as airways go.

For the 12% of these patients with unrecognized esophageal intubations, the airway was not managed.

How is that control?

Control suggests something that has been accomplished, something that can be considered completed, something that can be checked off. This subconscious, or even conscious, approach to airway management is part of the problem. If you are managing the airway you are constantly reassessing it and looking to maintain oxygenation and, much more importantly, ventilation. Airway management is never a task that has been completed. Airway management is a process that requires perpetual vigilance. Control suggests just the opposite.

This is like the approach to success. Success is a way of doing things, not an easily definable goal. The goal is continually changing as one is presented with different complications.

If we look at intubation as control, once the tube is in, if we saw what we think was the tube going through the cords, how aggressive are we in looking for evidence that we were wrong?

There is one thing that is pretty consistent with unrecognized esophageal intubations. The medic/nurse/doctor thought the tube was in the trachea. They thought the airway was controlled.

They had stopped looking for evidence that the tube was in the wrong place.

They had become complacent with their assumed control.

What I want to know is how the hell did 8 friggin’ people live with a tubed gut??

Those had to be tubes that got dislodged at the ED door or bedside moving the pt.

How the hell did 8 friggin’ people live with a tubed gut??

They were probably breathing adequately on their own around the misplaced tube. Where is the evidence that all of these patients needed to be intubated? That all of these patients needed to have their airways controlled?

Where is the evidence that the tube suddenly migrated to the esophagus at the ED?

I am under the impression that endotracheal tubes are not any more migratory than coconuts. Besides, good airway management (unlike airway control) involves continual assessment of tube placement. Unrecognized esophageal endotracheal tubes should not happen with good airway management.

These GI medics were only controlling access to the esophagus, and probably not even doing that well. It isn’t as if they were aware of what was going on with the airway. Control implies that there is no longer a need to remain aware of what is going on.

They certainly were not demonstrating any awareness of what was going on with the airway.

No. I believe these are the same as other groups of patients, who survived in spite of being esophageally intubated. They were spontaneously breathing. They were breathing around the tube. It isn’t as if the tube was blocking the trachea, since it was not in the trachea even a little bit. They were overcoming some of the medics’ best efforts to kill them.

With this group of medics, there is no reason to give them the benefit of the doubt about tube placement. They should have had waveform capnography, but even without waveform capnography there should be a much lower unrecognized esophageal intubation rate

Paramedics successfully intubated 95.5% (1,582) of all patients receiving succinylcholine, 94% (1,045) of trauma patients, and 98% (538) of medical patients. They were unable to intubate 4.5% (74) of the patients. All of these were successfully managed by alternative methods. Unrecognized esophageal intubation occurred in six (0.3%) patients. The addition of capnography and a tube aspiration device, in 1990, decreased the incidence of esophageal intubations.[2]

12% vs. 0.3%.

Six (0.36%) unrecognized esophageal intubations were discovered in the emergency department or at autopsy. Only one (0.06%) of these occurred since the addition of capnography and a tube aspiration device in 1990. In this patient, a zero reading on the capnograph was ignored and not verified by a tube aspiration device or by removing the tube and re-intubating the patient.

That is the kind of problem that continues to exist even in places that use waveform capnography – and there is no acceptable excuse for not using waveform capnography.

The problem is that the tube is in the mouth. The medic/nurse/doctor thinks the tube is in the right place, for whatever reason, then the medic/nurse/doctor ignores all evidence to the contrary.

Maybe the tube was in originally, but came out en route. We have no way of knowing because the medics have no way of showing evidence of where the tube was. If we have a series of printouts of a good waveforms, we know that the tube was either in the trachea or above the cords, but resting with the tip of the tube in the top of the trachea. Without waveform capnography, we have the medic’s word vs. the word of the unrecognized esophageal tube.

Is the medic telling a lie, or is the tube telling a lie?

We are very good at deceiving ourselves about what we want to believe. That is why we need to continually be looking for evidence that the tube is in the wrong place. That is why we should avoid using words that lead to airway complacency. that is why we should avoid using the word control. We should also avoid this fixation with, I saw the tube go through the cords. that is more self-deception. The only justification for it is to satisfy people who are incompetent at teaching and incompetent at assessment.

Footnotes:

^ 1 Prehospital intubations and mortality: a level 1 trauma center perspective.
Cobas MA, De la Peña MA, Manning R, Candiotti K, Varon AJ.
Anesth Analg. 2009 Aug;109(2):489-93.
PMID: 19608824 [PubMed – indexed for MEDLINE]

PubMed states that the full text article is free at the journal site, but it is not. This seems to have been posted on all of the Anesthesia & Analgesia abstracts at PubMed.

^ 2 Prehospital use of succinylcholine: a 20-year review.
Wayne MA, Friedland E.
Prehosp Emerg Care. 1999 Apr-Jun;3(2):107-9.
PMID: 10225641 [PubMed – indexed for MEDLINE]

.

Prehospital Intubations and Mortality – A Level 1 Trauma Center Perspective II

Also posted over at Paramedicine 101. Go check out the rest of what is there.

A new study of EMS intubation appears to show that prehospital intubation is a bad thing.

I do not agree. I wrote about this earlier in Part I.

Let me point out some more of the ways that I think this study demonstrates that the problems, and there are big problems, are with the medical oversight, more than with the paramedics.

During the study period, trauma patients were initially treated in the prehospital setting by fire rescue personnel of various municipalities and with different experience levels; typically, the fire rescue personnel trained as paramedics perform an average of 1–3 tracheal intubations per year and must undergo periodic assessments of their training and ability in airway management and intubation skills.[1]

That’s an average of 1 – 3 tubes per year.

Not per month.

Not per quarter.

Per year. An average of 1 – 3 tubes.

Does anybody want to guess what the reason is?

Miami is not a low population are. Miami, Florida is not the location of the Fountain of Youth, although Ponce de León is rumored to have wandered around Florida looking for the Fountain of Youth. There is no reason to believe that intubation happens at a different rate in Miami, as opposed to Boston, Massachusetts or Bellingham and Whatcom Counties, Washington. Let’s compare the number of intubations from the much larger study I cited before.[2] Over 20 years they intubated 94% of 1,045 trauma patients. An excellent record of consistent quality. In Miami, they intubated 68% of 203 trauma patients over about 3 years.

Miami has 203 trauma patients with attempted intubation arriving at this one trauma center over just less than 3 years. 203/3 = 68 trauma intubation attempts per year.

In Washington, they had 1,045 trauma intubation attempts over 20 years. 1,045/20 = 52 trauma intubation attempts per year. In Miami, they are averaging 1 to 3 intubation attempts per medic per year. In Washington, they have requirements for far more intubations per medic.

In Miami, 12% unrecognized esophageal intubations. In Washington, only one unrecognized esophageal intubation from the time they started using waveform capnography to the end of the study. A much longer period than the entire Miami study period.

This training includes didactic education in endotracheal intubation, alternative airway techniques, and skill simulation. Extensive education is provided in the pharmacology, indications, contraindications, and complications of the paralytic agent used, succinylcholine. Following didactic training, each student must successfully complete a minimum of 20 intubations, in the operating room, under the supervision of a board-certified anesthesiologist. Additionally, paramedics are required to successfully intubate at least one patient monthly for three years, post certification, and one per quarter thereafter. At least one intubation, annually, must be performed under an anesthesiologist’s supervision.[2]

In Washington, they have fewer intubation attempts. They should have less experience at intubation. However, in Washington, the number of intubation attempts is divided by a much smaller number of medics.

In Miami, they have the EMS equivalent of clown cars full of medics showing up for just one patient.

Why do they need so many medics?

They don’t. This is just politics. They do not understand that beyond a certain point, more medics just results in a dilution of skill. This is the More is Better mantra.

In Miami, they seem to have gone way past that point.

And they kept on going. Look at the way they approach airway management, then compare it to what I quoted from the Washington study. The difference is dramatic.

For Miami medics, all they say is: and must undergo periodic assessments of their training and ability in airway management and intubation skills.

Hasn’t that been a success beyond their wildest dreams.

Success?

It worked. The blame is falling on the medics, not on the medical directors who designed this abattoir. Not that the medics are blameless, but where is the medical direction?

What do they do to keep the tubes-per-medic-per-year so ridiculously low?

They keep the number of medics unreasonably high.

Emergency medicine residents, for example, are required to perform between 35–200 ETIs prior to graduation.

Research has demonstrated that paramedic students require at least 15–20 intubations to attain basic skills proficiency. The National Standard Curriculum for Emergency Medical Technician—Paramedic requires only five intubations prior to graduation.[3]

The American Heart Association recommends that ALS providers perform a minimum of six–12 intubations a year to remain credentialed in the procedure. EMS systems that have reported a high ETI success rate require a minimum of 15 ETIs per provider per year for credentialing. Only extremely busy EMS systems could ever achieve this level of practice.[3]

Miami is an extremely busy EMS system.

Why do they feel the need to minimize the experience level of the medics?

The medical directors in Miami don’t seem to begin to understand what they are doing.

12% unrecognized esophageal intubations pretty much screams incompetence.

Six (0.36%) unrecognized esophageal intubations were discovered in the emergency department or a autopsy. Only one (0.06%) of these occurred since the addition of capnography and a tube aspiration device in 1990. In this patient, a zero reading on the capnograph was ignored and not verified by a tube aspiration device or by removing the tube and re-intubating the patient.[2]

This appears to be beyond their capabilities of Miami. They have been doing an excellent job in Washington, but Miami has been happy to ignore the problem. Maybe the results of this study will cause them to change, but how could they have been this blind until now?

Footnotes:

^ 1 Prehospital intubations and mortality: a level 1 trauma center perspective.
Cobas MA, De la Peña MA, Manning R, Candiotti K, Varon AJ.
Anesth Analg. 2009 Aug;109(2):489-93.
PMID: 19608824 [PubMed – indexed for MEDLINE]

PubMed states that the full text article is free at the journal site, but it is not.

^ 2 Prehospital use of succinylcholine: a 20-year review.
Wayne MA, Friedland E.
Prehosp Emerg Care. 1999 Apr-Jun;3(2):107-9.
PMID: 10225641 [PubMed – indexed for MEDLINE]

Paramedics successfully intubated 95.5% (1,582) of all patients receiving succinylcholine, 94% (1,045) of trauma patients, and 98% (538) of medical patients. They were unable to intubate 4.5% (74) of the patients. All of these were successfully managed by alternative methods. Unrecognized esophageal intubation occurred in six (0.3%) patients. The addition of capnography and a tube aspiration device, in 1990, decreased the incidence of esophageal intubations.

^ 3 The Disappearing Endotracheal Tube – Historic skill threatened by lack of pratice and new devices
by Bryan E. Bledsoe, DO, FACEP, EMT-P and William E. Gandy, JD, LP, NREMT-P
March 2009 JEMS Vol. 34 No. 3
Article

.

Prehospital Intubations and Mortality – comment from Herbie

Also posted over at Paramedicine 101. Go check out the rest of what is there.

Herbie made these comments in reply to Prehospital Intubations and Mortality: A Level 1 Trauma Center Perspective I.

A couple of things:

1. These studies always seem to forget the fact that we, as Paramedics, receive these patients in atrocious conditions: pinned in cars, crap in the airway, etc, etc, etc. Of course there are going to be misses; however, that is NOT an excuse.

Prehospital use of succinylcholine: a 20-year review.
Wayne MA, Friedland E.
Prehosp Emerg Care. 1999 Apr-Jun;3(2):107-9.
PMID: 10225641 [PubMed – indexed for MEDLINE]

Paramedics successfully intubated 95.5% (1,582) of all patients receiving succinylcholine, 94% (1,045) of trauma patients, and 98% (538) of medical patients. They were unable to intubate 4.5% (74) of the patients. All of these were successfully managed by alternative methods. Unrecognized esophageal intubation occurred in six (0.3%) patients. The addition of capnography and a tube aspiration device, in 1990, decreased the incidence of esophageal intubations.

94% of over a thousand trauma patients successfully intubated. That seems to make it clear that EMS can intubate trauma patients well.

That system did have succinylcholine, while the Miami medics did not, but outside of EMS, does anybody intubate trauma patients without succinylcholine?

This is similar to the way we approach pain management, sedation, and nitrates for hypertensive CHF. If we allow any treatment at all, it is probably going to be limited to inadequate treatment. There are some places that allow EMS to deliver appropriate patient care, but they do not seem to be the ones in the big studies that get all of the press.

Calmly providing appropriate care is just not glamorous or newsworthy.

2. The other major problem is Paramedic Oversaturation. Everyone thinks they’re entitled to a Paramedic; they’re not. It’s simple math. If you have 1 MICU covering an area that intubates 100 patients a year, that’s about 25 per provider (4 full-timers). Add another MICU, cut all the numbers in half. You see the point.

On this, we completely agree.

Another problem is that with a limited number of paramedics, we are able to pick and choose the best available. When everybody is a paramedic, we take what we can get. We scrape the bottom of the barrel, then we scrape some more.

A patch and a pulse? That’s asking too much! Can’t I choose one or the other for my job requirement? How else will I con the population into believing that more medics means more marvelous medicky mojo.

3. It doesn’t help that ORs and the like are turning to LMAs.

I don’t really see this as a problem. Yes, we should try to get more live intubation practice for paramedics, but there is no good reason to believe that we cannot make up for a lot of the decreased live intubation opportunities with simulations provided by good, creative instructors.

Part of the intubation problem is the emphasis on live intubation practice. Simulations are not taken seriously in many medic programs. We do ourselves and our students a disservice, when we encourage them to believe that live intubation practice is essential, that anything else is not good enough. Simulation is the future of EMS airway management, especially in the rural setting, where patients requiring actual airway management may not be common. Agencies need to cooperate and pool resources to be able to regularly get their medics to practice on simulators. Or they need to admit that intubation is something that is beyond their means.

The rural EMS experience is the opposite in the cities, where the administrators and politicians have decided that, when skills have been diluted down to the point where they no longer exist, they are best. Homeopathic EMS airway management.

Both are methods of inflicting medics, with a lack of airway skill and a lack of airway experience, on a helpless population. Both demonstrate a criminal disregard for the well being of the patients abused by these medics.

3a. It doesn’t help that ORs are skittish about letting medic students hone their skill.

Hone implies that there are some skills to begin with. If the thing keeping medics from being good at intubation is a lack of live intubation practice, then I don’t think there is a skill being honed. It is merely a turd being polished.

Intubation skill does not depend on live intubation experience.

I would much rather see medics using a BVM during their OR time, than intubating. Good BVM use is far more important than intubation skill. Good BVM use is much more about assessment skills. Excellence with a BVM needs to be a prerequisite for beginning intubation training. Intubation encourages more of a set it and forget it attitude. If you doubt that, how do you explain all of these esophageal tubes?

12%? One out of every eight intubations was left in the wrong place.

Not only did they miss the trachea, but they did not recognize their mistakes. The whole time the tube was in the wrong place, the medics did not realize it.

The one unforgivable sin of airway management is an unrecognized esophageal tube.

It is OK to use a BVM, as long as the patient is being ventilated.

It is OK to use a CombiTube, as long as the patient is being ventilated.

It is OK to use an LMA, as long as the patient is being ventilated.

It is OK to use a crichothyrotomy, as long as the patient is being ventilated.

It is even OK to use a properly placed endotracheal tube, as long as the patient is being ventilated. I will not be critical of that.

But, It is not OK to use an endotracheal tube placed in the esophagus, not recognize that the tube is in the esophagus, and mindlessly keep oxygenating the stomach.

The gold standard is not intubation. The gold standard is ventilation by whatever means of airway management happens to be appropriate. BVM, LMA, CombiTube, crichothyrotomy, the patient protecting his own airway, et cetera. The method does not matter. The result is what matters.

4. Common sense and physics still take over: the best way to get oxygen to the lungs is a direct route; that direct route is the ET tube.

The best way to get the oxygen to the lungs and the CO2 out of the lungs, is the method that is the most effective and the least harmful. The removal of CO2 is actually more important than the delivery of O2

How easy is it going to be to place the tube properly? How much of an interruption in ventilation? How much hyperventilation afterward? How much of a vagal stimulus? How much of an increase in intracranial pressure?

We have research that shows that during intubation attempts, medics induce hypoxia, hypercarbia, increased intracranial pressure, and other things that may be more harmful than any possible intubation benefit.

We need outcomes research. Something to show when intubation actually is good for the patient. In order to do that, we need to limit the research to systems with medics competent at intubation and medical directors competent at the oversight of paramedics.

I’m not holding my breath waiting for that to happen.

These systems exist, but the medical directors seem to be pretty busy doing the other things that competent medical directors do.

.

Prehospital Intubations and Mortality: A Level 1 Trauma Center Perspective I

Also posted over at Paramedicine 101. Go check out the rest of what is there.

A new study looking at EMS intubation appears to show that prehospital intubation is a bad thing.

I do not agree.

Let me point out the ways that I think this study demonstrates where the problems are. And there are big problems. The problems are with the medical oversight, more than with the paramedics. This does not absolve the paramedics of responsibility for their lack of skill.

Control of the airway is the first priority for the management of critically ill patients and is prioritized in established patient-management algorithms, such as Advanced Cardiac Life Support and Advanced Trauma Life Support.[1]

From the first sentence, we disagree. Control of the airway is the wrong way to think about airway management. We never have control of the airway. Even a properly placed endotracheal tube does not mean control. Control suggests that something does what you want it to do.

Having a properly placed endotracheal tube does not mean that you can get the airway to do what you want it to do.

Having a properly placed endotracheal tube does not even mean that you can get the endotracheal tube to do what you want it to do.

What do we want it to do?

Little things, like remaining properly placed, not kinking, not becoming obstructed with mucus, not separating at the adapter, not separating from the BVM (Bag Valve Mask), not having the cuff deflate, having the cuff be properly inflated, et cetera.

As you can see, control is a foolishly optimistic description of what an endotracheal tube provides.

But that is just an unimportant semantic distinction.

Our choice of words is important. We should use words that mean what we intend them to mean. The meaning of the words we use should match what we mean. Otherwise how do the speaker and the listener understand each other?

They don’t?

Exactly.

Tell people that an endotracheal tube provides control. Plenty of them will ignore the many possible ways that a properly placed endotracheal tube does not mean control.

Maybe, but you keep asking for evidence. Where is your evidence?

Look at all the research on prehospital intubation. Thousands of intubations and attempted intubations have been studied. Some research demonstrates that intubation can be performed excellently in the prehospital setting.[2]

Then we have this new study, and plenty of others with similarly pathetic results, that show that if you do not take intubation seriously, you your patient will not do well.

I believe, but cannot prove, that a part of the reason for the bad intubation results is from not using terminology correctly. For example, if I state that the tube is in the airway, I do not mean that the tube passes through the airway on the way to the esophagus. This is technically accurate, but not what one wants to know when asking if the tube is in the airway, is it?

No, but control is a different term.

Yes, but it appears to be similarly misunderstood. Elsewhere in this study . . .

Oh good, we’re going to move beyond the first sentence.

Elsewhere in this study, there is a breakdown of the method of airway management. This gives you more of an idea of the way that they misunderstand airway management. PHI = PreHospital Intubation.

The esophageal tubes are not really viewed differently from the use of the LMA[3] or the CombiTube[4] or crichothyrotomy.[5]

This approach demonstrates a complete misunderstanding of airway management.

The use of an alternative airway should not be seen as a failure. While it is true that it is not a successful intubation, that does not mean that it is not successful airway management. Airway management should be viewed as a continuum.[6] Airway management is not a choice between intubation is good vs. any other form of airway management is bad.

Also, teaching that airway takes priority over everything else is finally being recognized as a mistake.

Footnotes:

^ 1 Prehospital intubations and mortality: a level 1 trauma center perspective.
Cobas MA, De la Peña MA, Manning R, Candiotti K, Varon AJ.
Anesth Analg. 2009 Aug;109(2):489-93.
PMID: 19608824 [PubMed – indexed for MEDLINE]

PubMed states that the full text article is free at the journal site, but it is not. This seems to have been posted on all of the Anesthesia & Analgesia abstracts at PubMed.

^ 2 Prehospital use of succinylcholine: a 20-year review.
Wayne MA, Friedland E.
Prehosp Emerg Care. 1999 Apr-Jun;3(2):107-9.
PMID: 10225641 [PubMed – indexed for MEDLINE]

Paramedics successfully intubated 95.5% (1,582) of all patients receiving succinylcholine, 94% (1,045) of trauma patients, and 98% (538) of medical patients. They were unable to intubate 4.5% (74) of the patients. All of these were successfully managed by alternative methods. Unrecognized esophageal intubation occurred in six (0.3%) patients. The addition of capnography and a tube aspiration device, in 1990, decreased the incidence of esophageal intubations.

^ 3 Laryngeal Mask Airway
Wikipedia
Article

^ 4 Combitube
Wikipedia
Article

^ 5 Cricothyrotomy
Wikipedia
Article

^ 6 The Airway Continuum
by Kelly Grayson
EMS1.com
Article

.

RSI, Risk Management, and Rocket Science

This is the way that RSI (Rapid Sequence Induction, or Rapid Sequence Intubation) starts out. An impressive presentation. Usually by means of a PowerPoint presentation.

Sometimes there will be problems that cannot be handled in the normal fashion.

Competent preparation includes the ability to bail out, such as the use of rescue airways, as necessary.

When that preparation is not handled competently, even the rescue airway is not really available to the less-than-prepared.

The search for the highest level person to take the fall for the superiors becomes the focus of the aftermath. Those who create the environment that encourages this failure rarely suffer any significant consequences.

Why should I use the example of the Challenger (STS-51-L), January 28, 1986?

Unreasonably optimistic claims of safety.

Irresponsible oversight.

Failure.

The blame is focused away from the dominant cause.

NASA claimed that the reliability of the Space Shuttle was so great that the risk of an accident was 1/100,000 flights. With this kind of reliability, they could fly twice a week for a thousand years with only one serious failure. The Rogers Commission found that even a 1/100 flight accident rate was unreasonably optimistic.

NASA was claiming that the missions were more than 1,000 times safer than they had any reason to believe. Did they learn from this and improve? Dr. Richard Feynman wrote his own appendix to the findings of the Rogers Commission.

If a reasonable launch schedule is to be maintained, engineering often cannot be done fast enough to keep up with the expectations of originally conservative certification criteria designed to guarantee a very safe vehicle. In these situations, subtly, and often with apparently logical arguments, the criteria are altered so that flights may still be certified in time. They therefore fly in a relatively unsafe condition, with a chance of failure of the order of a percent (it is difficult to be more accurate).

Official management, on the other hand, claims to believe the probability of failure is a thousand times less. One reason for this may be an attempt to assure the government of NASA perfection and success in order to ensure the supply of funds. The other may be that they sincerely believed it to be true, demonstrating an almost incredible lack of communication between themselves and their working engineers.

And he concluded with:

For a successful technology, reality must take precedence over public relations, for nature cannot be fooled.[1]

After all, everyone was watching their performance, how could they continue to make bad decisions that resulted in deaths?

February 1, 2003. Columbia (STS-107). 17 years and only 88 flights later.

“It’s just a flesh wound.”

Not a laughing matter, but the way that NASA has handled risk assessment has been one big example of what not to do. In some places, medical oversight of RSI appears to be following a similar path, just on a much lower budget.

The advantage of hindsight, and the opportunity to second-guess decisions made since February 2003, permeates these observations. All of them were, however, written prior to the launch of STS-114.[2] It is also important to recognize that the behaviors and attitudes described here were not chance occurrences that were observed only once or twice, but that emerged numerous times throughout the Task Group’s interaction with NASA. The intent of these observations is to help NASA leadership identify and rectify these concerns. We will address four main areas: rigor, risk, requirements, and leadership.[3]

How does a medical director not know that medics are not using waveform capnography to assess placement of endotracheal tubes?

A. They use it. I just know.

B. I follow up with the hospital staff to find out what they saw as good and bad about the packaging and care of unstable patients, especially RSI patients.

C. We can’t afford waveform capnography. We use something “just as good.”

D. What’s waveform capnography?

Only one of these is an acceptable answer.

Imagine if you had a device that could monitor the patient’s ECG (ElectroCardioGram) and 12-lead ECG, NIBP (Non-Invasive Blood Pressure), pulse oximetry, and waveform capnography. All with the ability to store the records for dozens of patients, so they can be recovered, or transferred to other media, later.

Printer problem? No problem. Can you say accountability?

Now imagine that you can use waveform capnography to prove that the ETT (EndoTracheal Tube) was not in the esophagus.

If a medical director is responsible for the oversight of paramedic intubation and is not using waveform capnography, there is a serious lack of understanding of risk management.

“We can’t afford waveform capnography.”

Show a lawyer the evidence that the tube was not in the esophagus – a waveform capnography recording from just after the tube was placed, repeated recordings while en route, and another recording just prior to moving the patient to the hospital stretcher – the lawyer will realize that there is no money to be made from this EMS organization.

When that is not the case, it is just your word against an expert witness. An expert witness is someone who gets paid a lot of money (something you claim not to have) to go all over the country to testify that the patient care was incompetent. There are a lot of very persuasive, charming expert witnesses. They make a lot of money. They are good at convincing juries that the patient care was incompetent. Juries love hearing that a simple device, although expensive, was available, but not used. The medical director decided the patients’ lives were not worth this much. Or the EMS agency made that decision and the medical director did not have enough sense or integrity to challenge the medical orders of the EMS agency.

Is waveform capnography idiot-proof?

Nothing is idiot-proof, especially in EMS, but waveform capnography is as close as you are going to get to idiot-proof in airway management.

If EMS is to be improved, we need to get more medical directors who understand risk management and waveform capnography.

This should not even be a topic for debate. There is no valid argument against waveform capnography.

If you cannot afford waveform capnography, then you cannot afford to intubate.

If you decide that intubation should be done anyway, you do not deserve any compassion when your actions result in disability and/or death.

Idiocy is not a valid excuse.

Leadership?


For a successful technology, reality must take precedence over public relations, for nature cannot be fooled.[4]

If you prefer, you may substitute God for the term nature.

All of the images used are in the public domain.

Some other posts about this:

RSI, Intubation, Medical Direction, and Lawyers.

RSI Problems – What Oversight?

More RSI Oversight

Misleading Research

Intubation Confirmation

More Intubation Confirmation

Footnotes:

^ 1 Report of the Presidential Commission on the Space Shuttle Challenger Accident (Also known as The Rogers Commission Report)
Volume 2: Appendix F – Personal Observations on Reliability of Shuttle
by R. P. Feynman
Conclusions
http://history.nasa.gov/rogersrep/v2appf.htm

^ 2 STS-114
Wikipedia
Article

^ 3 Return to Flight Task Group Final Report 8/17/05
A.2 Observations by Dr. Dan L. Crippen, Dr. Charles C. Daniel, Dr. Amy K. Donahue, Col. Susan J. Helms, Ms. Susan Morrisey Livingstone, Dr. Rosemary O’Leary, and Mr. William Wegner.
Page 188
http://www.nasa.gov/pdf/125343main_RTFTF_final_081705.pdf This is an automatic download.
If that does not work, or you do not want to download the file, try:
http://www.scribd.com/doc/349834/NASA-125343main-RTFTF-final-081705

^ 4 The same as footnote 1
http://history.nasa.gov/rogersrep/v2appf.htm

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